PAL team of nurse case managers supports discharged patients of The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center and Howard County General Hospital. Pictured in the top row are: Susan Wolfe, Shelia Dennis, Noime Vidal and Mary Bornyek; bottom: Melissa McAdam-Cox, Sharon Schromsky, Shavona Jones, Ute Leon and Jeff Godwin. Stephanie Hopkins is not pictured.

johns hopkins health system hospitals care for patients who often have complex medical conditions or challenges related to social determi-nants of health. When these patients are discharged, how well they manage their care at home can make the difference between a smooth recovery or a return to the hospital.

One program the health system has initiated to provide support during this critical transition is the Patient Access Line (PAL), which marks its fifth anni-

versary this month. With PAL, patients going home without other services receive a call from an experienced nurse case manager to see how they are doing and ensure they understand their care plans. Launched under a Center for Medicare & Medicaid Innovation grant, PAL was designed to provide the follow-up needed to improve care and reduce the costs associated with potentially avoidable utilization.

Melissa Richardson, interim vice president for care coordination for the

Johns Hopkins Health System, says the calls also represent an opportunity for the PAL case managers to offer comfort, provide additional teaching and review important details such as medication regimens and doctors’ appointments. “We want to know things like, ‘How are you feeling? Same, better or worse?’ If it’s worse, we’re going to dig into that and engage the appropriate follow-up—whether suggesting a call to the doctor, a visit by a transition guide or a trip to the ED.”

News for JHM faculty, staff and students on the East Baltimore campus and beyond Sept. 13, 2018

InsiderHopkins

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born with spina bifida in a society that shuns disabilities, Zayne Callahan lingered for seven years in the base-ment of an orphanage in China before a chance encounter resulted in adoption.

Bullied so harshly in middle school that she retaliated by becoming a bully herself, Haleemat Adekoya knew she had gone too far when her parents threatened to send her to live with family back in Nigeria.

Left behind at age 5 in Honduras with a relative who would physically and emotionally abuse her, Sary Guerra is

poised to become the first in her family to graduate from high school.

Guerra dreams of getting her bache-lor’s degree, going to medical school and becoming a rheumatologist. Callahan is on a path to become a pediatrician, and Adekoya wants to be a child psychologist and open a center for lost youth.

They were three of six students chosen from more than 200 participants to share their life stories at the fifth annual Johns Hopkins CARES Symposium on July 26 in the Armstrong Medical Education

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Nurse Intervention Marks 5 Years of Smoothing Transitions of Care

Eager Park Block Party Strengthens Community Ties

Students Share Stories of Their Paths to Pursue Medical Science

The Johns Hopkins Hospital recently partnered with Sisters Together and Reaching (STAR) for their annual block party at Eager Park, a revitalized community space two blocks north of The Johns Hopkins Hospital. Through the sweltering August heat and humidity, hundreds of East Baltimore residents attended, and there were over 50 vendors who provided health education and screenings, social services, music, food and activities. The event, which drew hospital staff members, politicians and local residents, also continued to tie Johns Hopkins and the East Baltimore community even closer together.

The theme of the health festival was “meeting in the middle, bridging the gap between the old and the new.” Redonda Miller, president of The Johns Hopkins Hospital and a speaker at the event, felt that the theme was apropos for the

From left: Students Erica Wright, Maria Guerra Garcia, Haleemat Adekoya, Sary Guerra, Zayne Callahan and Daniela Sedano pose with Vice Dean for Education Roy Ziegelstein and CARES Symposium keynote speaker Alicia Arbaje. Photo by Rafael Leon.

The Johns Hopkins Hospital Patient and Family Advisory Council volunteers educated block party attendees.

Johns Hopkins Medicine

Town Meeting

Friday, Sept. 14

Noon to 1 p.m. in Hurd Hall

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Noteworthy Information and Events

Prepare for Open Enrollment for 2019 Benefits Johns Hopkins is committed to providing employees with a competitive benefits package that positively impacts their health and well-being. Open enrollment for 2019 benefits for Johns Hopkins Hospital/JHHSC employees is from Oct. 15 to Oct. 31, and open enrollment for school of medicine employees is from Oct. 19 to Nov. 7. The Johns Hopkins Hospital Benefits Fair is Tuesday, Sept. 25, from 7 a.m. to 4 p.m. in the Chevy Chase Conference Center, and the school of medicine benefits fair is Oct. 9 from 10 a.m. to 4 p.m. in Turner Concourse.

Celebrating Our Employee Superheroes Grab your cape and get ready to celebrate nearly 1,900 employee superheroes during the 2018 Employee Appreciation Service Awards Ceremony on Thursday, Sept. 13, from noon to 1:30 p.m. in the Turner Auditorium. Employees celebrating a milestone workforce anniversary from five to 60 years will be recognized. Plan to attend this out-of-this-world dedication.

Nominate a Top Johns Hopkins Nurse Do you know a Johns Hopkins nurse who goes above and beyond for patients and families every day? Consider nominating her or him for Baltimore magazine’s next Top Nurses issue. Nominations can come from peers, supervisors and patients—submitted through the magazine’s online survey, at baltimoremagazine.com/marketing/top-nurses-2019-survey. Submit your Top Nurse nominations by Dec. 2018.

From the Editor Hopkins Insider is published once a month—on Thursdays—by Johns Hopkins Medicine Marketing and Communications. Email your submissions at least 14 days prior to the requested publication date to Stephanie Price, editor, sprice20@jhmi.edu, for consideration. The upcoming publication date is Oct. 11.

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Over the years, PAL has expanded from a staff of four to 11 nurses and now serves patients from The Johns Hopkins Hospital, Johns Hopkins Bayview Medi-cal Center and Howard County General Hospital. In total, the service has con-nected with more than 41,700 patients since 2013.

The impact is positive. Data show that in a 40-month period between January 2014 and April 2017, there was a 29 per-cent relative reduction in the readmission rate for the nearly 38,300 patients who received PAL calls. Those who did not get connected with PAL—usually be-cause no one answered the phone or the line was disconnected—had 45 percent increased odds of readmission compared with those who did. During this interval, PAL prevented 777 readmissions, result-ing in $11.8 million in cost savings.

PAL Manager Susan Wolfe praises the training, dedication and persistence of her staff members and other provid-ers who go the extra mile to ensure all patients get safe, quality care.

She points to a Howard County General Hospital physician who made a home visit to check on a patient with a concerning cough and whose caregivers were out of town; the intervention for an elderly Johns Hopkins Hospital patient who was in respiratory distress but hesitant to call 911; and the persistence to reach a Johns Hopkins Bayview Medical Center patient whose phone number was disconnected and who was later found to need emergency services. (See sidebar.)

With the PAL call, nurses are able to sense fear and anxiety, identify medi-cal issues such as shortness of breath or uncontrolled pain, and expertly assess a patients’ ability to care for themselves. “I’m proud that they connect with the patients with the intention of making a difference,” Wolfe says.

Richardson agrees: “There is very, very strong desire within that group to make sure that the patient is ‘tucked in’ after they’ve left the hospital or ED.”

—Janet Anderson

Patient Access Line

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Building. Thousands apply for CARES (Career, Academic and Research Ex-periences for Students), a network of programs that provide paid internships and educational opportunities across the medical campus to Baltimore area high school students, along with undergradu-ate and graduate students from around the country.

More than 100 faculty members serve as mentors to the students who share a desire to pursue careers in medicine or research. For many of the high school students, CARES is an opportunity to land a fruitful summer job with exposure to careers and mentors in the medical sciences, says Gerri Cole, pro-gram manager in the Office of Student Pipeline Programs at the Johns Hopkins University School of Medicine.

“Many of the high school programs are two years, so the first year they are learning about different lab skills and shadowing a mentor, and the second year they are actually in labs doing the work,” said Cole, noting that a goal is to generate a homegrown workforce and improve the likelihood that local students will pursue careers in science, public health or medicine.

During the symposium, students

deliver professional presentations to an audience of more than 350 attend-ees, bolster their academic and social confidence, and share their journeys, struggles and lessons learned in achiev-ing their dreams while inspiring a generation of future leaders.

Poster Sessions Showcase Summer AccomplishmentsNicole Felix Velez, a junior at the University of Puerto Rico-Mayaguez, was one of the 200 students selected to showcase their summer work in one of two poster sessions.

Felix Velez’s poster, titled “Murine Kidney-on-a-Chip Model for Polycystic Kidney Disease,” showed how study-ing cells of polycystic kidney disease (a common genetic disorder identified by the growth of cysts in the kidneys) may lead to development of treatments. “What was amazing about this experi-ence was that I was able to work with a microfluidic device that my mentor made himself in order to measure and study this disease,” says Velez.

Students Share Their Authentic StoriesDaniela Sedano, a student at the George Washington Carver Center for Arts and Technology high school, spoke of the

difficulties she experienced taking care of her Spanish-speaking grandparents. At age 10 she became the sole caregiver to her grandmother, who struggled with type 2 diabetes and later stomach can-cer, and her grandfather who suffered with Alzheimer’s disease. Sedano’s stud-ies faltered as she would often need time off from school to take her grandparents to doctor appointments because they trusted only her to be their primary interpreter.

“The opportunity to be exposed to these diseases at such a young age is what pushed me further to pursue a ca-reer in medicine,” said Sedano. “Thanks to my family, I was able to find what I want to pursue in the future, either neurology because of my grandfather’s Alzheimer’s or geriatrics because of my grandmother. I also want to increase the number of bilingual physicians in Baltimore so that other kids don’t have to miss out on their childhood in order to be interpreters for their families.”

—Michael Keating

Students Share Stories

connection between the hospital and East Baltimore. “Dating back to our founding in 1889, we’ve always had a relationship with our community,” she says. Miller believes the partnerships with local organizations are vital to make a difference in Baltimore, saying “Johns Hopkins cannot do it alone.”

Since its inception, STAR has established itself as a group focused on improving community health. Debra Hickman, co-founder and CEO of STAR, sees Johns Hopkins’

participation in the block party as fitting since they share the same goals: to offer East Baltimore the care and resources needed. “Our well-being, prosperity and education—all of those things are important to both [Johns Hopkins] as well as the neighbors living in the community,” Hickman says.

Baltimore City Mayor Catherine Pugh spoke about how the relationship between the hospital and the local area will continue to benefit both parties. “I don’t think

you can have a better partner than Johns Hopkins,” she said. “For Johns Hopkins to really ingratiate itself in the community bodes well for all of the organizations and so forth that surround the neighborhood.” With the success of events such as this, both can expect to continually grow and prosper in the future.

—Philip Hiotis

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Eager Park

PATIENT ACCESS LINE (PAL) STATISTICS

41,700patients served

since 2013

29%reduction in

readmission from 2014–2017

prevented readmissions

777

$11.8 MILLION

in cost savings